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Like other residents and medical students in the late 1990s, I was taught to assess the “5th vital sign”—pain—and address it, usually with opioids. My colleagues and I were taught that the medical community had long ignored the treatment of pain and it was now time to redress that wrong. Our teachers, medical boards, and professional associations (and always in the background, the pharmaceutical companies) urged us to assess and treat pain aggressively (1).

Thus, with no training in pain management, and no training in addiction, I was soon prescribing large doses of opioids to treat pain in patients who were clearly not improving and who were marginally functional at best. They crowded the examination room with physical complaints and stories of unemployment, fractured households, and deepening depression. According to their Global Assessment of Functioning, they were drowning in dysfunction. According to my 15-minute clinical assessment, this meant I should raise their methadone dose.